• Journal of Korean Society of Archives and Records Management
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• v.13 no.1
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• pp.107-134
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• 2013

Many hospitals introduce the electronic medical record systems (EMRS) to implement a digital type of hospital. However, there are various problems in managing and preserving medical records. Systems, such as OCS, PACS, and EMR, are independently operated without formal standards related to medical records management. To manage medical records effectively, distributed medical records including paperand electronic-type should be managed in an integrated manner. With its analysis of the current status in the management of medical records of J University Hospital, this study proposes methods to solve the problems extracted from the results of the analysis, and a management model for an integrated medical records management based on the process of records management of ISO 15489.

• Journal of Digital Contents Society
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• v.11 no.2
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• pp.135-144
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• 2010

Medical records are very important records and should not be modified after creation. The current medical records are liable to improper modification. With the development of information technology, electronic medical records (EMR) are used widely. For the EMR, cryptographic primitives may be used to develop techniques to prevent medical record modofication. In this research, a technique to prevent improper medical record prevention is proposed. It uses crytographic primitives such as linked hash, digital signature, and electronic notarization. A prototype system is also developed for performance analysis. The proposed method makes the medical record modification impossible with a small amount of additional cost.

• Proceedings of the KAIS Fall Conference
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• 2001.05a
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• pp.378-382
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• 2001

최근 의료계에서는 의무기록을 전자문서화 하는 연구가 활발히 진행되고 있다. 더불어 전자의무기록의 표준화에 대한 노력도 병행되고 있으며, XML이 이에 대한 대안 중 하나로 제시되고 있다. 이에 따라 기존 병원 정보시스템에 구축된 의료정보를 XML로 변환하는 방법에 대한 연구가 요구된다. 본 논문에서는 간략화한 의무기록을 XML로 표현하는데 필요한 DTD를 제안하며, Java 프로그래밍 언어를 이용하여 기존 병원의 Legacy Database에 기록된 의무기록 자료를 XML 문서로 변환하고, 전자의무기록 XML 문서를 병원정보시스템에서 활용할 수 있도록 Database에 기록하는 Converter를 구현하였다.

• Quality Improvement in Health Care
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• v.15 no.1
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• pp.113-120
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• 2009

문제: 의무기록 질 관리의 어려움 목적: 의무기록의 질 향상 의료기관: 고려대학교 의료원 안암병원 의료정보팀 질 향상 활동: 의무기록의 질 향상을 위해 입퇴원기록지 24시간 이내 작성율 향상, 입원기록지 24시간 이내 작성율 향상, 외과계 N-C 기재율 감소, 경과기록지 작성율 향상, 일일입퇴원기록지 작성율 향상, STAFF 서명 완성일 단축 활동을 하였다. 개선효과: 의무기록 작성에서 같은 내용을 반복 작성해야 하는 번거로움을 해소하였고, 작성자(의료진) 중심의 프로그램 개선과 개발된 프로그램의 지속적인 모니터링으로 의무기록의 질이 향상되었다.

• Quality Improvement in Health Care
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• v.14 no.1
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• pp.69-74
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• 2008

문제: 전자의무기록(EMR) 시행 후 의무기록 정리율의 저하와 질적인 측면에서의 충실성과 정확성에 대한 문제점이 제기되었다. 목적: 전자의무기록의 정리율과 충실성 검토를 통하여 문제점을 파악하고 개선점 찾아 의무기록 정리율을 향상시키고 충실성을 높이고자 하였다. 의료기관: 서울시에 소재한 대학병원 의무기록과 질 향상 활동: 전자의무기록의 문제점을 개선하기 위하여 사용자 편의를 위한 EMR 프로그램 수정 및 보완, 진단 수술 관련 작업, 업무개선, 교육, 홍보 등의 활동을 실시하였다. 개선효과: 의무기록 정리율, 전자인증미비, 경과기록 기재일수, 퇴원요약 주진단 적합률, 기록지별 필수항목 기재율, 충실성에서 향상이 이루어졌다.

• Proceedings of the Korea Information Processing Society Conference
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• 2008.11a
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• pp.676-678
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• 2008

임상 의무기록에 나타나는 많은 두문자어들은 기계적인 처리과정에서 의무기록의 모호성을 크게 증가시키기 때문에, 정보추출이나 텍스트 마이닝을 하기 전에 전처리 과정으로 의무기록이 정규화 되어야 한다. 본 연구에서는 임상 의무기록 중 하나인 퇴원요약지에 사용된 약어와 두문자어들의 모호성을 제거하기 위한 정규화 시스템을 설계하고 구현했다. 정규화를 위해 문맥정보를 이용하여 의무기록의 종류와 기록내 위치정보를 파악하였고 이를 이용하여 약어와 두문자어의 의미를 학습하고 분류하였다. 본 연구에서 구현한 정규화 시스템은 실험에서 6가지 두문자어들이 가지는 16가지 의미들에 대해 94.7%의 정확률을 얻었다.

• Journal of the Korean Society for information Management
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• v.29 no.3
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• pp.257-285
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• 2012

As the electronic medical records systems (EMRs) are introduced into the hospitals in Korea and the needs of chief stakehoders of medical records are changed, the environments related to creating and managing medical records has been changed dynamically. At this moment it might be meaningful to examine medical records based on records management principles rather than information management principles. The purpose of this paper is to apply the KS X ISO 1549 standards, which covers the principles of records management, to hospital medical records management and assess the current quality of medical records management, and define a few tasks of improvement for hospitals. To achieve this goal, this study has performed following activities: Firstly, principles that could be applied to medical records management were prepared for each record management steps described in the standards, such as capture, registration, classification, storage, access, trace and disposition, and 22 principles were selected from those 7 steps of the record management. Secondly, the Y hospital, which is affiliated with a medical school in Seoul, was chosen to evaluate the current situation regarding medical records management. The department head of the medical records management team in Y hospital was interviewed and the present status was evaluated according to each principle. Thirdly, tasks for improvement were suggested, in such stages as access, trace and disposition. With this study as a cornerstone, useful implications are expected to be gathered from future studies that apply standards for metadata of records, management systems for records, and record management systems to medical record management in hospitals.

• Journal of Korean Society of Archives and Records Management
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• v.13 no.3
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• pp.151-171
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• 2013

To comprehend the importance and necessity of record management metadata standard implemented in an electronic medical records system, a survey was undertaken to 50 medical records managers in charge of 5 major hospitals in Seoul. Analysis of the survey results was performed by averaging the responses given by those who answered the survey. SPSS was utilized for statistical analysis. Managers of medical records placed importance on metadata that are related to security of records, such as "levels of security", "types of access to medical records", "levels of authorization granted to personnel", and "users accessing medical records". It shows that these managers need the functions of privacy protection in ERMS. Metadata on "external disclosure" had the lowest level but those surveyed with more than 7 years of experience placed greater importance in this area more those surveyed with less than 7 years of experience in a hospital. This shows that managers need the functions of external disclosure to meet the needs of third partiesfor medical research and medical education.

• Journal of the Korea Academia-Industrial cooperation Society
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• v.9 no.3
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• pp.787-793
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• 2008

This paper investigates the issuance of medical records of patients and caregivers who have obtained medical records from the Medical Record Information Center of "a university" in Daejeon from January through March in 2006. According to the structural equation, "the time zone for issuance of medical records" was -0.01 as a path coefficient against "how medical records are issued" and +0.86 against "ordinary characteristics." As shown above, privacy and confidentiality are what really matters in the management of medical records. Therefore, they must be protected regardless of whether the medical records are hard or electronic copies.

• Journal of Digital Contents Society
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• v.12 no.4
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• pp.501-510
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• 2011

Most of electronic medical record systems which have been built in Korean hospitals are based on source oriented medical record approach. These systems hardly satisfy diverse objectives owing to the innate imperfections in system architecture and development methodology. Thus, the hybrid of source oriented and problem oriented approach is highly desirable. The purpose of this study is to present an architecture and methodology required to construct hybrid electronic medical record system and to develop a prototype based on them. Analyzing the clinical processes and data requirements of problem oriented medical record approach we developed a software process model as weel as an architecture model which consists of legacy system, clinical data repository, problem list database, prospective plan database, user interface, and synchronization procedures.